Soft tissue reconstruction

ABSTRACT

Methods and instruments for reconstructing soft tissues of a skeletal joint such as for example of the foot or hand are presented.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation application of U.S. patentapplication Ser. No. 15/006,863, filed Jan. 26, 2016, which is acontinuation application of U.S. patent application Ser. No. 13/654,013,filed Oct. 17, 2012 and issued as U.S. Pat. No. 9,241,784, which is acontinuation-in-part of U.S. patent application Ser. No. 13/527,648,filed Jun. 20, 2012 and issued as U.S. Pat. No. 8,784,427, which claimsthe benefit of U.S. Provisional Application No. 61/568,137, filed Dec.7, 2011, U.S. Provisional Application No. 61/505,992, filed Jul. 8,2011, U.S. Provisional Application No. 61/506,000, filed Jul. 8, 2011,and U.S. Provisional Application No. 61/506,004, filed Jul. 8, 2011. Allof the cross-referenced non-provisional and provisional applications areincorporated herein by reference in their entirety.

FIELD OF THE INVENTION

The invention relates to methods and instruments for reconstructing softtissues of a skeletal joint such as for example of the foot or hand.

BACKGROUND

Various conditions may affect skeletal joints such as the elongation,shortening, or rupture of soft tissues associated with the joint. Jointfunction may be restored by reconstruction of the soft tissuesassociated with the joint.

SUMMARY

The present invention provides methods for reconstructing soft tissuesassociated with joints.

In one aspect of the invention, a method of reconstructing soft tissueadjacent a metapodial phalangeal joint of a human extremity includesforming a metapodial bone tunnel in the metapodial bone; forming aphalangeal bone tunnel in the proximal phalanx; placing a graft betweenthe metapodial and phalangeal bone tunnels; and securing the graft.

In another aspect of the invention, a method of reconstructing softtissue adjacent a metapodial phalangeal joint includes positioning adrill guide adjacent the joint; engaging a first reference portion ofthe drill guide with a first anatomic landmark; aligning a first guidingportion of the drill guide in alignment with a medial-dorsal aspect ofthe metapodial bone; aligning a second guiding portion of the drillguide in alignment with a lateral-dorsal aspect of the metapodial bone;guiding a cutter with the first guiding portion to form a first tunnelinto the metapodial bone; and guiding a cutter with the second guidingportion to form a second tunnel into the metapodial bone intersectingthe first tunnel.

In another aspect of the invention, a method of reconstructing softtissue adjacent a metapodial phalangeal joint includes positioning adrill guide adjacent the joint; engaging a first reference portion ofthe drill guide with a first anatomic landmark; aligning a guidingportion of the drill guide in alignment with the proximal phalanx; andguiding a cutter with the guiding portion to form the phalangeal tunnel.

In another aspect of the invention, a method of reconstructing anaccessory collateral ligament adjacent a metatarsophalangeal joint of ahuman foot includes positioning a drill guide adjacent the joint;aligning a first guiding portion of the drill guide in alignment withthe anatomic attachment of an accessory collateral ligament on themetatarsus; aligning a second guiding portion of the drill guide inalignment with the proximal phalanx; guiding a cutter with the firstguiding portion to form tunnel in the metatarsus; guiding a cutter withthe second guiding portion to form a tunnel in the proximal phalanx;placing graft material at least partially into the first tunnel; placinggraft material at least partially into the phalangeal tunnel; andsecuring the graft material in the tunnels.

In another aspect of the invention, a method of reconstructing anaccessory collateral ligament adjacent a metatarsophalangeal joint of ahuman foot includes positioning a drill guide adjacent the joint;aligning a guiding portion of the drill guide in alignment with theanatomic attachment of an accessory collateral ligament on themetatarsus; guiding a cutter with the guiding portion to form a tunnelin the metatarsus; placing graft material such that it passes from thetunnel around a portion of the intermetatarsal ligament and back to thetunnel; and securing the graft material relative to the tunnel.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the present invention will be discussed withreference to the appended drawings. These drawings depict onlyillustrative examples of the invention and are not to be consideredlimiting of its scope.

FIG. 1 is side elevation view of the human foot illustrating anatomicreference planes;

FIG. 2 is a dorsal view of the metatarsus and proximal phalanx of theright second metatarsophalangeal joint of the human foot;

FIG. 3 is a medial view of the bones of FIG. 2;

FIG. 4 is a lateral view of the bones of FIG. 2;

FIG. 5 is a perspective view of an illustrative example of a guideaccording to the present invention;

FIG. 6 is a top plan view of the guide of FIG. 5;

FIG. 7 is an exploded perspective view of the guide of FIG. 5;

FIG. 8 is an exploded top plan view of the guide of FIG. 5;

FIG. 9 is a perspective view of the guide of FIG. 5 showing a positionof the guide;

FIG. 10 is a perspective view of the guide of FIG. 5 showing a positionof the guide;

FIG. 11 is a perspective view of the guide of FIG. 5 showing a positionof the guide;

FIG. 12 is a perspective view of the guide of FIG. 5 showing a positionof the guide;

FIG. 13 is a perspective view of the guide of FIG. 5 showing a positionof the guide;

FIG. 14 is a perspective view of a tube useable with the guide of FIG.5;

FIG. 15 is a side elevation view of the tube of FIG. 14;

FIG. 16 is a side elevation view of the guide of FIG. 5 in use with anMTP joint;

FIG. 17 is side elevation view of the guide of FIG. 5 in use with an MTPjoint;

FIG. 18 is a side elevation view of the guide of FIG. 5 in use with anMTP joint;

FIG. 19 is a top plan view of the guide of FIG. 5 in use with an MTPjoint;

FIG. 20 is a side elevation view of the guide of FIG. 5 in use with anMTP joint;

FIG. 21 is a top plan view of the guide of FIG. 5 in use with an MTPjoint;

FIG. 22 is a side elevation view of the guide of FIG. 5 in use with anMTP joint;

FIG. 23 is a top plan view of the guide of FIG. 5 in use with an MTPjoint;

FIG. 24 is a side elevation view of the guide of FIG. 5 in use with anMTP joint;

FIG. 25 is a top plan view of the guide of FIG. 5 in use with an MTPjoint;

FIG. 26 is a perspective view of an illustrative example of a guideaccording to the present invention.

FIGS. 27-35 illustrate soft tissue reconstruction of the MTP joint ofthe human foot using tunnels formed with a guide according to thepresent invention;

FIG. 36 is a perspective view of an illustrative example of a guideaccording to the present invention;

FIG. 37 is front elevation view of the guide of FIG. 36;

FIG. 38 is a side elevation view of the guide of FIG. 36;

FIG. 39 is a top plan view of the guide of FIG. 36 taken along line39-39 of FIG. 38;

FIG. 40 is a top plan view of the guide of FIG. 36 in use with an MTPjoint;

FIG. 41 is a side elevation view of the guide of FIG. 36 in use with anMTP joint;

FIG. 42 illustrates soft tissue reconstruction of the MTP joint of thehuman foot using tunnels formed with a guide according to the presentinvention;

FIG. 43 is a side elevation view of an illustrative example of a guideaccording to the present invention;

FIG. 44 illustrates soft tissue reconstruction of the MTP joint of thehuman foot using tunnels formed with a guide according to the presentinvention; and

FIG. 45 illustrates soft tissue reconstruction of the MTP joint of thehuman foot using tunnels formed with a guide according to the presentinvention.

DESCRIPTION OF THE ILLUSTRATIVE EXAMPLES

The following illustrative examples illustrate instruments andtechniques for treating skeletal joints. Instruments and techniquesaccording to the present invention may be used in conjunction with anyskeletal joint but the illustrative examples are shown in a size andform most suitable for the joints of the hand and foot. The hand andfoot have a similar structure. Each has a volar aspect. In the hand thevolar, or palmar, aspect includes the palm of the hand and is thegripping side of the hand. In the foot the volar, or plantar, aspect isthe sole of the foot and is the ground contacting surface during normalwalking. Both the hand and foot have a dorsal aspect opposite the volaraspect. Both the hand and foot include long bones referred to asmetapodial bones. In the hand, the metapodial bones may also be referredto as metacarpal bones. In the foot, the metapodial bones may also bereferred to as metatarsal bones. Both the hand and foot include aplurality of phalanges that are the bones of the digits, i.e. thefingers and toes. In both the hand and foot, each of the most proximalphalanges forms a joint with a corresponding metapodial bone. This jointincludes a volar plate or band of connective tissue on the volar side ofthe joint. The joint also includes collateral ligaments on the medialand lateral sides of the joint. A transverse ligament, orintermetapodial ligament, connects the heads of the metapodial bones. Inthe hand the joint is typically referred to as the metacarpophalangealjoint having a palmar plate on the palmar side, collateral ligamentsmedially and laterally, and a transverse ligament connecting themetacarpals. In the foot the joint is typically referred to as themetatarsophalangeal joint having a plantar plate on the plantar side,collateral ligaments medially and laterally including proper collateralligaments and accessory collateral ligaments, and a transverse ligamentalso known as the transverse metatarsal ligament or intermetatarsalligament.

For convenience, the illustrative examples depict the use of instrumentsand techniques according to the present invention on metatarsophalangeal(MTP) joints of the human foot. The illustrative instruments andtechniques are also suitable for use on metacarpophalangeal (MCP) jointsof the human hand and other surgical sites. To better orient the reader,the MTP joint and basic anatomic references are explained in more detailbelow.

FIG. 1 illustrates the anatomic planes of the foot that are used forreference in this application. The coronal plane 10 extends from themedial aspect 12 to the lateral aspect of the foot and from dorsal 14 toplantar 16 and divides the foot between the toes and heel. The sagittalplane 18 extends anterior 20 to posterior 22 and dorsal 14 to plantar 16and divides the foot into medial and lateral halves. The transverseplane extends anterior 20 to posterior 22 and medial to lateral parallelto the floor 26.

FIGS. 2-4 illustrate the metatarsus 30 and proximal phalanx 50 of thesecond MTP joint of the right foot. The medial and lateral epicondyles32, 34, located on the medial-dorsal and lateral-dorsal aspects of themetatarsus 30 respectively, are the origins of the medial and lateralproper collateral ligaments (PCLs) 36, 38 and the medial and lateralaccessory collateral ligaments (ACLs) 40, 42 of the MTP joint. Themedial PCL inserts at the medial-plantar aspect 52 and the lateral PCLinserts at the lateral-plantar aspect 54 of the proximal phalanx 50. Themedial and lateral ACLs fan out and insert into the medial and lateralborders of the plantar plate 44 respectively. The metatarsus includes ametatarsal head 46 having an articular surface 48 and the proximalphalanx includes a phalangeal head 56 having an articular surface 58.The metatarsus 30 further includes a longitudinal axis 60 extendinglength wise down the center of the bone.

The terms “suture” and “suture strand” are used herein to mean anystrand or flexible member, natural or synthetic, able to be passedthrough material and useful in a surgical procedure including withoutlimiting the above filaments, fabric, tendon, ligament, and fascia. Theterm “graft” is similarly defined as any member, natural or synthetic,that is used to reconstruct a soft tissue and includes sutures. The term“transverse” is used herein to mean crossing as in non-parallel. Theterm “bight” is used herein to mean a bend or loop formed in theintermediate portion of a suture.

FIGS. 5-13 illustrate an exemplary guide 2300 for guiding a cutter tocut a bone. In this illustrative example, the guide 2300 is configuredas a drill guide to guide a drill, punch, pin, broach or the like toform holes in the bones adjacent the second MTP joint of the right humanfoot. The drill guide 2300 includes a pair of plate-like members 2302,2304 joined at a hinge 2306 allowing a single degree of freedom suchthat the members may be pivoted between a first position and a secondposition. The members include a plurality of fixation holes forreceiving fixation devices, e.g. fixation pins or screws, to secure themembers to underlying bones and guide holes to guide the formation oftunnels in the underlying bones to facilitate soft tissue repair,replacement, and/or augmentation around the joint. The first member 2302is configured to overlie the metatarsus and the second member 2304 isconfigured to overly the phalanx.

The first member 2302 includes a planar top surface 2309, a first end2308 having fixation holes 2310, and a metatarsal guide portion 2312.The metatarsal guide portion 2312 has a feature for guiding a cutter. Inthe illustrative example of FIGS. 5-13, the metatarsal guide portion2312 includes medial and lateral spaced apart, hollow, tabularextensions 2314, 2315 each projecting upwardly and outwardly from thetop surface 2309 and configured as a drill guide able to guide a drill,punch, broach, pin or the like. The tubular extensions 2314, 2315 areoriented so that their axes 2311, 2313 intersect below the metatarsalguide portion 2312. A mounting yoke 2320 having opposed spaced apartarms extends from the first end 2308 to a second end 2322 defining apair of eyelets 2324 which straddle a block 2326 mounted on the secondmember 2304. The block 2326 has a hole 2328 aligned with the eyelets2324. A bolt 2330 and nut 2325 join the eyelets 2324 and block 2326. Alocking cam 2332 is pinned to the head 2334 of the bolt 2330 forrelative rotation about a pin 2336 and includes a lever 2337 extendingfrom the cam for rotating the cam 2332 between a locked and unlockedposition. The bolt 2330 and locking cam 2332 are operable to press theeyelets 2324 together against the block 2326 to frictionally lock themembers 2302, 2304 in relative angular relationship.

The second member 2304 includes an elongated handle 2340 having alongitudinal axis 2341, a planar top surface 2343, fixation holes 2338and a phalangeal guide portion 2344. The phalangeal guide portion 2344has a feature for guiding a cutter. In the illustrative example of FIGS.5-13, the phalangeal guide portion 2344 includes medial and lateralspaced apart, hollow, tubular extensions 2346, 2347 each projectingupwardly and configured as a drill guide able to guide a drill, punch,broach, pin or the like along axes 2345, 2349. The phalangeal guideportion 2344 includes a pair of grooves 2348 for receiving the yoke 2320of the first member to increase the relative positional accuracy andstability of the members relative to one another when the members arelocked in the second coaxial position. The second member 2304 furtherincludes a head referencing member 2350 having a reference surface 2351for engaging an anatomic landmark. In the illustrative example of FIGS.5-13, the head referencing member 2350 has a concave spherical surfaceable to engage the articular surface of the metatarsal head. Oppositethe concave surface is a convex back surface able to engage thearticular surface of the phalangeal head. The second member furtherincludes a pair of oppositely, laterally extending bosses 2342 forreceiving a band to secure the guide 2300 to the phalanx.

FIG. 9 depicts the guide 2300 locked in the first parallel position.FIG. 10 depicts the guide 2300 with the cam 2332 unlocked by rotatinglever 2337 and the first member 2302 rotated part-way toward the secondposition. FIG. 11 depicts the guide 2300 with the first member 2302rotated further toward the second position. FIG. 12 depicts the guide2300 with the first member rotated fully into the second position. FIG.13 depicts the guide 2300 with the cam 2332 locked to fix the first andsecond members 2302, 2304 in the second position.

The relative position and orientation of the reference surface 2351 ofthe head referencing member 2350, the handle axis 2341, the handle topsurface 2343, the phalangeal extensions 2346, 2347, and the metatarsalextension 2314, 2315 are determined from averaged anthropometric datarelating the metatarsal head articular surface, metatarsal longitudinalaxis, and transverse plane of the human body to the medial and lateralPCL origins and insertions when the guide 2300 is locked in the secondposition and placed on the bone with the reference surface 2350 engagedwith the metatarsal head 2106, the handle axis 2341 parallel to the axis110 of the metatarsus, and the handle top surface 2343 parallel to thetransverse plane such that the metatarsal extension axes 2311, 2313intersect the PCL origins and the phalangeal extension axes 2345, 2349intersect the PCL origins.

FIGS. 14 and 15 illustrate an elongated tube 2400 that may be used withguide 2300 to protect soft tissue, facilitate engaging a cutter with theguide, and stabilize the cutter. For example, a long narrow drill,punch, pin, broach, or the like may be difficult to align with theextensions 2314, 2315, 2346, 2347 and/or may be so flexible that ittends to skive off the bone surface. The tube 2400 includes a tubularshaft 2402 having a proximal end 2404, a distal end 2406, and alongitudinal axis 2408 extending from the proximal end 2404 to thedistal end 2406. The proximal end is radially enlarged to form a knob2410. The knob 2410 includes a counter sink 2412 forming a funnel-likelead-in to the inner bore 2414 of the tubular shaft 2402. The outside ofthe shaft 2402 is sized to slide into the extensions of the guide 2300and extend through the guide 2300 to contact the underlying bone. Theshaft 2402 provides positive guidance of the cutter to the bone surface.The knob 2410 provides the user with a gripping surface spaced away fromthe inner bore 2414 to protect the user from being pricked by the cutteras the cutter is engaged with the inner bore 2414. The countersink 2412guides the cutter into the inner bore 2414.

FIGS. 16-25 illustrate the guide 2300 in use to guide a cutter to formholes in the bones of the second MTP joint to facilitate, e.g., thereconstruction of the joint. The guide 2300 is brought near the jointwith the first and second members folded in the first position as shownin FIG. 16. The head referencing member 2350 is inserted into the jointspace between the metatarsus 2100 and phalanx 2200 as shown in FIG. 17.The concave reference surface 2351 is registered with the convexarticular surface 2108 of the metatarsal head and the convex referencesurface opposite the concave reference surface is registered with theconcave articular surface of the proximal phalanx. The guide handle axis2341 is oriented parallel to the axis 110 of the metatarsus and theguide handle top surface 2343 is oriented parallel to the transverseplane as shown in FIGS. 18 and 19. The first member is then pivoted intothe second position as shown in FIGS. 20 and 21. The orientation of theguide 2300 may be checked again. The cam is actuated to lock the membersrelative to one another and fixation devices, e.g. pins 2360, may beplaced in the guide fixation holes to fix the members to the bones asshown in FIGS. 22 and 23. An elastic band 2362 may be wrapped around thephalanx and engaged with the bosses 2342 to secure the second member2304 to the phalanx in addition to, or as an alternative to, thefixation pins 2360.

Once the members are aligned and secured, the guide is used to guide acutter to form one or more tunnels in the bones as shown in FIGS. 24 and25. The cutter 2364 may be engaged directly with an extension of a guideportion and advanced into the bone. Alternatively, an elongated tube2400 may first be engaged with the guide portion and extended to thebone surface. The cutter may then be engaged with the elongated tube2400 and advanced into the bone.

The illustrative guide of FIGS. 5-13 includes two separate membershinged together. Alternatively, the guide may be provided as twoseparate guides each having a joint reference surface and useableindependently to drill tunnels in the metatarsus and proximal phalanx.Alternatively, the hinge may be removed, and the two members combinedinto one non-movable unitary structure 2600 as shown in FIG. 26.

The illustrative guides of FIGS. 5 and 26 are configured to reference tothe anatomy of the right second MTP joint of the human foot to guide acutter to form tunnels in the metatarsus and phalanx that intersect themedial and lateral PCL origins and insertions to facilitate routing andattaching ligaments to reconstruct the PCLs. The guide may be mirroredfor use on the left foot and the guide may be provided in sizes fordifferent MTP joints and various sized feet. However, it has been foundthat the variation of the PCL origin and insertion anatomy issurprisingly small for the second MTP joint across a wide range of footsizes and it is possible to provide a single sized guide for all leftsecond MTP joints and another for all right MTP joints for feet from atleast a woman's U.S. size 7 to a man's U.S. size 11.

FIGS. 27-35 illustrate soft tissue reconstruction of the MTP joint ofthe human foot using tunnels formed with the guides of FIG. 5 or 26. Forexample, a PCL or ACL may be partially or fully torn due to acute traumaor chronic progressive failure. Likewise, these soft tissues may beintentionally released from their bony origins or attachments tofacilitate a surgical procedure. The instruments and techniques of thepresent invention provide a way to reconstruct these soft tissues.

FIGS. 27-31 depict an illustrative method to reconstruct a PCL. In theillustrative example of FIGS. 27-31, the medial PCL is reconstructed byplacing a graft from the PCL origin on the distal aspect of themetatarsal to the PCL insertion on the proximal aspect of the proximalmetatarsal. FIGS. 27-29 detail bone tunnels formed using guide 2300 or2600. For example, the metatarsal guide portion 2312 has guided a cutterto form a medial-dorsal tunnel 2500 extending from the medial PCL origininto the metatarsus and a lateral-dorsal tunnel 2502 extending from thelateral PCL origin into the metatarsus. The tubular extensions 2314,2315 of the metatarsal guide portion 2312 are oriented so that theiraxes intersect below the dorsal surface of the metatarsus. Thus, thetunnels 2500, 2502 intersect within the metatarsus and provide a pathfor fixing grafts to reconstruct one or both of the PCLs. The phalangealguide portion 2344 has guided a cutter to form a tunnel 2510 extendingfrom the medial-dorsal surface 2512 of the phalanx to the insertion 2514of the lateral PCL on the lateral-plantar surface of the phalanx. Theholes 2560 are formed by fixation members 2360 used to hold the guide inplace.

FIG. 30 depicts a graft 2504 with a proximal suture 2506 stitched to itsproximal end and a distal suture 2508 stitched to its distal end. Theproximal suture 2506 is threaded through the metatarsal bone tunnels byinserting it into the medial-dorsal tunnel 2500 and retrieving it fromthe lateral-dorsal tunnel 2502. The distal suture 2508 is threadedthrough the phalangeal bone tunnel 2510 by passing it from plantar todorsal through the tunnel.

In FIG. 31 the sutures 2506, 2508 have been tensioned to pull the endsof the graft 2504 into the tunnels. The suture may be secured by anysuitable method such as tying, securing over a button, securing with aninterference fastener, or other suitable method. Similarly, the graft2504 may be secured directly such as by interference fastener, pinning,or other suitable method.

FIGS. 32 and 33 depict an illustrative method to reconstruct a PCL. Inthe illustrative example of FIGS. 32 and 33, a bilateral reconstructionis shown in which both the medial and lateral PCLs are reconstructed.For example, the metatarsal guide portion 2312 of guide 2300 has guideda cutter to form a medial-dorsal tunnel 2500 extending from the medialPCL origin into the metatarsus and a lateral-dorsal tunnel 2502extending from the lateral PCL origin into the metatarsus. The tubularextension 2314, 2315 of the metatarsal guide portion 2312 are orientedso that their axes intersect below the dorsal surface of the metatarsus.Thus, the tunnels 2500, 2502 intersect within the metatarsus and providea path for fixing grafts to reconstruct one or both of the PCLs. Thephalangeal guide portion 2344 has guided a cutter to form a tunnel 2510extending from the medial-dorsal surface 2512 of the phalanx to theinsertion 2514 of the lateral PCL on the lateral-plantar surface of thephalanx. The guide has also guided a cutter to form a tunnel 2520extending from the lateral-dorsal surface 2522 of the phalanx to theinsertion of the medial PCL on the medial-plantar surface of thephalanx. These two phalangeal tunnels cross each other withoutintersecting. A graft 2524 with a medial suture 2526 stitched to one endand a lateral suture 2528 stitched to another end. One of the sutures2526, 2528 is threaded through the metatarsal bone tunnels and tensionedto pull the graft 2524 into the metatarsal bone tunnels. The medialsuture 2526 is threaded through the phalangeal tunnel 2520 intersectingthe medial PCL insertion by inserting it into the medial-plantar openingof the tunnel 2520 and retrieving it through the lateral-dorsal openingof the tunnel 2520. The lateral suture 2528 is threaded through thephalangeal tunnel 2510 intersecting the lateral PCL insertion byinserting it into the lateral-plantar opening of the tunnel 2510 andretrieving it through the medial-dorsal opening of the tunnel 2510.

In FIG. 33 the sutures 2526, 2528 have been tensioned to pull the graftends into the phalangeal tunnels. The sutures may be secured by anysuitable method such as tying, securing over a button, securing with aninterference fastener, or other suitable method. Similarly, the graftmay be secured directly such as by interference fastener, pinning, orother suitable method. In the illustrative example of FIGS. 32 and 33,the sutures have been secured by tying them together over the bonebridge between the tunnels 2510, 2520.

The medial and lateral ACLs of the MTP joint have origins that arecoincident with the PCLs and insert into the junction between the edgesof the plantar plate 44 and the intermetatarsal ligament (IML) 2700 atthe medial and lateral borders of the plantar plate. The IML is a narrowband of connective tissue that extends between and connects together theheads of the metatarsal bones. The same tunnels used to reconstruct thePCLs may be used to reconstruct the ACLs such that the illustrativeguides 2300, 2600 configured for PCL reconstruction may also be used forACL reconstruction. FIGS. 34 and 35 depict an illustrative method toperform a bilateral ACL reconstruction. The method begins as in thebilateral PCL reconstruction with the formation of bone tunnels 2500,2502 in the metatarsus and bone tunnels 2510, 2520 in the proximalphalanx. A graft 2702 is pulled through the metatarsal tunnels. The endsof the graft 2702 are passed through the IML 2700 at the anatomicinsertion of the ACL and then into the phalangeal tunnels 2510, 2520 andsecured. In the illustrative example of FIGS. 34 and 35 the graft issecured by tying sutures connected to the graft ends together over thebone bridge between the tunnels 2510, 2520. One or both ACLs may bereconstructed along with one or both PCLs. For example, a PCL graft 2504may be attached as described relative to FIGS. 27-33 along with the ACLgraft 2702.

The guides 2300, 2600 may have any number of cutter guides targeted atany desired anatomical feature. While the illustrative examples havedepicted a guide configured for ACL and PCL reconstruction of the righthuman MTP joint, the guide may be similarly configured to target otherligament reconstructions or other surgical procedures at other locationsthroughout the body.

FIGS. 36-39 depict an illustrative example of a guide 2800 for guiding acutter to cut a bone. In this illustrative example, the guide 2800 isconfigured as a drill guide to guide a drill, punch, pin, broach or thelike to form holes in the bones adjacent the second MTP joint of theright human foot. The guide includes a base member 2802. In theillustrative examples of FIGS. 36-39, the base member 2802 is an arcuatemember extending from a first end 2804 to a second end 2806. An indexingmember 2808 and a grip 2810 are attached to the base member 2802 nearthe first end 2804. A guide member 2812 having a feature for guiding atunnel forming implement is attached to the base member 2802 near thesecond end.

In the illustrative example of FIGS. 36-39, the indexing member 2808 andgrip 2810 are coaxial relative to a first longitudinal indexing axis2814. The indexing member 2808 is in the form of a sharply pointed foursided pyramid projecting inwardly on the concave side of the arcuatebase member 2802. The grip 2810 includes a riser post 2816 extendingupwardly from the convex side of the base member 2802 and is topped witha cylindrical thumb pad 2818 having a knurled perimeter 2820, anupwardly directed face having a central depression 2822 for receiving auser's thumb, and an alignment feature such for example an alignmentmark 2824 inscribed on the face. The illustrative guide member 2812 is atube having an interior bore for guiding a tunnel forming implement anddefining a bore axis 2826. The indexing axis 2814 and bore axis 2826form an angle between them of approximately 73 degrees and converge onthe convex side of the base member. The indexing axis 2814, bore axis2826, and alignment mark 2814 are oriented relative to one another basedon averaged anthropometric data relating the dorsal surface of themetatarsus, the metatarsal longitudinal axis, and the metatarsalepicondyles.

As shown in FIGS. 41 and 40, with the indexing member engaged with thedorsal cortex of the metatarsal bone, the indexing axis perpendicular tothe metatarsal axis, the alignment mark parallel to the metatarsal axis,and the bore axis directed toward the medial epicondyle, the bore axis2814 will project through the metatarsal bone and intersect the medialand lateral epicondyles 32, 34. These references may be adjusted so thatthe bore axis 2814 projects slightly dorsal of the medial epicondyle andslightly plantar of the lateral epicondyle in order to provideadditional clearance above the metatarsal bone medially for insertion ofa cutter such as a drill. When a bone tunnel 2828 is formed along thebore axis, the tunnel exits will approximate the origins of the medialand lateral PCLs and ACLs at the epicondyles 32, 34. FIG. 41 illustratesthe lateral opening of a tunnel 2828 formed using the guide 2800.

FIG. 42 illustrates reconstruction of the PCL and ACL similar to that ofFIGS. 27-35 but utilizing a tunnel through the metatarsal epicondylesformed using the guide 2800. For a unilateral repair, the tunnel may gopart way or all the way through the metatarsal bone and the graft may besecured using techniques such as tying, using interference devices, orother suitable methods. The tunnel 2828 may be used for PCLreconstruction, ACL reconstruction, and combined PCL and ACLreconstruction with the grafts 2504, 2704 routed as described relativeto FIGS. 27-35.

FIG. 43 illustrates a guide 2900 similar to the guide 2800 of FIG. 36but having a second guide member 2910 offset further plantar than afirst guide member 2812. The guide member 2910 is oriented to produce abone tunnel plantar the bone tunnel 2828 and useable to provide a tunnelfor ACL reconstruction distinct from the tunnel for PCL reconstruction.The lower tunnel may be useful where, for example, the PCL's are intactand it is desirable to provide a tunnel for ACL reconstruction that doesnot compromise the PCL origins. It may also be used, for example, toprovide separate tunnels for PCL and ACL reconstruction. The moreplantar second guide member 2910 may be provided alone on a guide withthe more dorsal first guide member 2812 omitted or they may both beplaced on the same guide as shown.

FIG. 44 illustrates two medial to lateral tunnels 2828, 2912 formedusing the guide 2900 of FIG. 43 and separate reconstructions of thelateral PCL and lateral ACL with grafts 2504, 2702. The reconstructionsshown in FIGS. 42 and 44 are hybrid constructs providing a combined PCL& ACL functional replacement utilizing a tunnel on the proximal phalanxfor the attachment of both grafts.

FIG. 45 illustrates an anatomic reconstruction of the PCL and ananatomic reconstruction of the ACL. The intact ACL is a fan shapedligament that originates at the epicondyle on the metatarsal head andinserts into the border of the plantar plate. The medial ACL insertsinto the medial border of the plantar plate and the lateral ACL insertsinto the lateral border of the plantar plate. In the illustrativereconstruction of FIG. 45, the tunnel 2912 is located approximately atthe origin of the ACL and a graft 2702 is passed from the tunnel 2912,under the intermetatarsal ligament 2700, and back to the tunnel 2912where both ends of the graft 2702 are fixed to form a triangular graftconstruct similar to the intact ACL anatomy. In a bilateral ACLreconstruction, separate medial and lateral grafts may be passed andfixed in the tunnel 2912 or a single graft may be passed through thetunnel and on each side of the metatarsal head with ends brought back tothe tunnel 2912 and fixed. The graft 2701 may pass around any portion ofthe intermetatarsal ligament 2700. For example, it may pass completelyaround the intermetatarsal ligament such that the portion includes theentire intermetatarsal ligament or it may pass through the metatarsalligament and around a portion less than the entire ligament. The graftmay pass through or around a portion of the plantar plate alone or incombination with the intermetatarsal ligament.

The surgical procedures and reconstructions relating to the MTP jointand surrounding bones may also be performed on corresponding joints andbones of the hand and such use is within the scope of the invention.

What is claimed is:
 1. A bone drill guide useable near a metatarsalphalangeal (MTP) joint of a human foot to guide the formation of a holein a bone that intersects a ligament boney attachment adjacent thejoint, the MTP joint including a metatarsal bone having a longitudinalaxis and a head with an articular surface, and a phalangeal bone havinga head with an articular surface, the bone drill guide comprising: abody having a reference member comprising a first reference portion, asecond reference portion, and a first drill guiding portion, the firstand second reference portions positioned on opposing sides of thereference member, the first reference portion engageable with at leastone articular surface of the MTP joint and with the second referenceportion engageable with at least one other articular surface of the MTPjoint, the first drill guiding portion being oriented relative to thefirst reference portion based on human anatomy relating the location ofa first ligament boney attachment to at least one articular surface ofthe MTP joint, the guide being operable to engage the first referenceportion with at least one articular surface of the MTP joint to positionthe first drill guiding portion in alignment with the boney attachmentof the first ligament.
 2. The bone drill guide of claim 1 furthercomprising a second drill guiding portion, the second drill guidingportion being oriented relative to the first and second referenceportions to align with a second ligament boney attachment simultaneouswith the alignment of the first drill guiding portion with the firstligament boney attachment.
 3. The bone drill guide of claim 1 whereinthe bone drill guide is operable to engage the first reference portionwith an anatomic landmark to position the first drill guiding portion inalignment with the first ligament boney attachment when the landmark isspaced away from the first ligament boney attachment.
 4. A bone drillguide useable near a metatarsal phalangeal (MTP) joint of a human footto guide the formation of a hole in a bone that intersects a ligamentboney attachment adjacent the joint, the MTP joint including ametatarsal bone having a longitudinal axis and a head with an articularsurface, and a phalangeal bone having a head with an articular surface,the bone drill guide comprising: a body having a first reference portionengageable with at least one articular surface of the MTP joint and afirst drill guiding portion, the first drill guiding portion beingoriented relative to the first reference portion based on human anatomyrelating the location of a first ligament boney attachment to at leastone articular surface of the MTP joint, the guide being operable toengage the first reference portion with at least one articular surfaceof the MTP joint to position the first drill guiding portion inalignment with the boney attachment of the first ligament, and whereinthe first reference portion comprises a member extending away from thebody and having a concave surface engageable with the metatarsal head.5. The bone drill guide of claim 4 wherein the concave surface isspherical and engageable with the metatarsal head, the sphericalengagement operable to constrain the guide in three translationaldegrees of freedom.
 6. The bone drill guide of claim 5 wherein the bodycomprises a guide longitudinal axis and a planar portion, the guidebeing operable, while the concave surface is engaged with the metatarsalhead, to align the guide longitudinal axis parallel to the longitudinalaxis of the metatarsal bone to eliminate two degrees of rotationalfreedom and to align the planar portion parallel to the transverse planeof the foot to eliminate a third degree of rotational freedom.
 7. Thebone drill guide of claim 4 wherein the concave surface is cylindricaland engageable with the metatarsal head, the cylindrical engagementoperable to constrain the guide in two translational degrees of freedom.8. The bone drill guide of claim 7 wherein the body comprises a guidelongitudinal axis and a planar portion, the guide being operable, whilethe concave surface is engaged with the metatarsal head, to align theguide longitudinal axis with the longitudinal axis of the metatarsalbone to eliminate one degree of translational freedom and two degrees ofrotational freedom and to align the planar portion parallel to thetransverse plane of the foot to eliminate a third degree of rotationalfreedom.
 9. A bone drill guide useable near a metatarsal phalangeal(MTP) joint of a human foot to guide the formation of a hole in a bonethat intersects a ligament boney attachment adjacent the joint, the MTPjoint including a metatarsal bone having a longitudinal axis and a headwith an articular surface, and a phalangeal bone having a head with anarticular surface, the bone drill guide comprising: a body having afirst reference portion engageable with at least one articular surfaceof the MTP joint and a first drill guiding portion, the first drillguiding portion being oriented relative to the first reference portionbased on human anatomy relating the location of a first ligament boneyattachment to at least one articular surface of the MTP joint, the guidebeing operable to engage the first reference portion with at least onearticular surface of the MTP joint to position the first drill guidingportion in alignment with the boney attachment of the first ligament,and wherein the body comprises first and second rigid members joinedtogether at a hinge in relative rotating relationship and the firstdrill guiding portion includes a hole defining a first drill guidingaxis through the first rigid member alignable with the boney attachmentof a ligament to the metatarsal bone.
 10. The bone drill guide of claim9 wherein the second rigid member includes a second drill guidingportion having a hole defining a second drill guiding axissimultaneously alignable with the boney attachment of a ligament to thephalangeal bone.
 11. The bone drill guide of claim 10 wherein the firstand second rigid members further include holes for receiving fixationmembers to attach the rigid members to the metatarsal and phalangealbones.
 12. A method of forming a tunnel in a bone near a bone joint tointersect a ligament boney attachment adjacent the bone joint, themethod comprising: positioning a guide adjacent the bone joint, theguide having a body comprising: a reference member having a firstreference portion and a second reference portion, the first referenceportion engageable with at least a first articular surface of the bonejoint, the second reference portion engageable with at least a secondarticular surface of the bone joint; and a first guiding portionoriented relative to the first reference portion based on human anatomyrelating anatomic landmarks associated with the kinematic operation ofthe bone joint to a ligament boney attachment; engaging the firstreference portion with the first articular surface and engaging thesecond reference portion with the second articular surface to positionthe first guiding portion in alignment with the ligament boneyattachment; and guiding a cutter with the first guiding portion to forma bone tunnel intersecting the ligament boney attachment.
 13. The methodof claim 12 wherein the first guiding portion is oriented relative tothe second reference portion based on the human anatomy relatinganatomic landmarks, and wherein the engaging includes the secondreference portion engaging the second articular surface simultaneouslywith the first reference portion engaging the first articular surface.14. The method of claim 12 wherein the first guiding portion comprises adrill guide, and wherein the cutter comprises a drill positioned withinand guided along the drill guide.
 15. The method of claim 12 wherein thebone joint is a metatarsal phalangeal (MTP) joint of a human foot, andwherein the first articular surface is positioned at a metatarsal headof a metatarsal bone of the human foot.
 16. A method of forming a tunnelin a bone near a bone joint to intersect a ligament boney attachmentadjacent the bone joint, the method comprising: positioning a guideadjacent the bone joint, the guide having a body comprising: a firstreference portion engageable with the bone joint; and a first guidingportion oriented relative to the first reference portion based on humananatomy relating anatomic landmarks associated with the kinematicoperation of the bone joint to a ligament boney attachment; engaging thefirst reference portion with a first anatomic landmark to position thefirst guiding portion in alignment with the ligament boney attachment;and guiding a cutter with the first guiding portion to form a bonetunnel intersecting the ligament boney attachment; and wherein the bonejoint is a metatarsal phalangeal (MTP) joint of a human foot, whereinthe first anatomic landmark comprises a metatarsal head of a metatarsalbone of the human foot, and wherein the first reference portioncomprises a member extending outwardly from the body and having aconcave surface, and wherein the engaging the first reference portioncomprises engaging the concave surface with the metatarsal head.
 17. Themethod of claim 16 wherein the concave surface is spherical, and whereinengaging the concave surface with the metatarsal head constrains theguide in three translational degrees of freedom.
 18. The method of claim17 wherein the body further comprises a guide longitudinal axis and aplanar portion, the method further comprising: aligning the guidelongitudinal axis parallel with a longitudinal axis of the metatarsalbone to eliminate two degrees of rotational freedom; and aligning theplanar portion parallel with a transverse plane of the human foot toeliminate a third degree of rotational freedom.
 19. The method of claim16 wherein the concave surface is cylindrical, and wherein engaging theconcave surface with the metatarsal head constrains the guide in twotranslational degrees of freedom.
 20. The method of claim 19 wherein thebody further comprises a guide longitudinal axis and a planar portion,the method further comprising: aligning the guide longitudinal axis witha longitudinal axis of the metatarsal bone to eliminate one degree oftranslational freedom and two degrees of rotational freedom; andaligning the planar portion parallel to a transverse plane of the humanfoot to eliminate a third degree of rotational freedom.